“The algorithm cannot say no, however. If it finds problems, it sends the request for review to a team of in-house nurses and doctors who consult company medical guidelines. Only doctors can issue a final denial.”<p>As a physician, I’ve had to speak to these so called “peers” in a peer to peer denials with both my clinic and hospital setting. They are usually people who aren’t physicians as a first line of their defense, ie therapist, nurses, etc. This weeds out the providers who either don’t care about the patient denial and blindly accept the denial, or patient has to take matters in their own hands just to get the care they need/deserve. Or worse, in the hospital that means the patient gets hit with a huge bill (already an insane number in the US even with insurance, so don’t get me started on this) or it gets delegated to another provider who has to deal with it. Quite often patients get denied medical and rehab services, esp after something debilitating like a stroke, trauma/accident, etc. and at that point the peer to peer is to weed the provider out. Usually someone will tell the patient you’ve been denied, either go home without the services they need or you fight it.<p>I fight it. Can’t count the number of times I’ve spoken to someone not in the field of medicine or if they are, not my field of medicine (both Family/Hospital Medicine). Often I’m fighting with an MD or “practitioner” who is some other field like a gynecologist about hospital medicine services or rehab. I’ve even had the pleasure of talking to a physical therapist and didn’t let me get a word in as we began the peer to peer. I now start of by asking for their credentials and field of speciality and demand a peer of my field to do the denying if they are so adamant about it “not being medically necessary”.<p>I have so much to say and could write a book about it. I just wish I had the money and connections to actually change the state of US of Corporate Medicine.
I feel like this should really be something people should lose their license over.<p>By deeming something <i>not medically necessary</i> they are (in my opinion) effectively practicing medicine. If they aren't qualified to practice that specialty, or aren't acting in the patients interest we should really be getting malpractice suits on them and stripping medical licenses.
Right? Lawyers can get into deep shit if they misrepresent their ability to well, represent a client on a case outside of their area of competence. How are medical professionals that often won't even tell you what they think about a test result and refer you to a specialist to actually get a diagnosis able to ethically represent what a patient actually needs?
Legally speaking the health plan employee isn't practicing medicine in that circumstance. The requesting provider is still free to treat the patient, they just won't be reimbursed by the health plan. The requesting provider can do it for free, or the patient can pay cash. I do understand that those aren't realistic options in most cases, I'm just explaining the legal distinction.
First off, thank you for taking the time to do it. I know most people don't agree on many things today, but most Americans agree the current system is stacked against them. Not to search very far, I have good insurance and I still have to deal with things that border on criminal.<p>Two, that book may be a good idea:D
As someone who needs expensive medication, thank you. I appreciate it.<p>2 questions:<p><pre><code> * This time, is it paid? Is it billable? Is it part of the visit I pay for?
* What can I - as a patient - do to make this process easier?</code></pre>
It's unpaid time, but that'll just get factored into the rates charged for billable things like appointments and procedures.
It's like any time spend on billing or administrative work, it's baked into the costs. (Administrative costs is a big component of rising healthcare costs.)<p>Depending on the issue, the patient may be needed to provide supporting paperwork, like previous diagnoses or treatment for providers. Other than that, not really, short of taking legal action.
seriously consider that book if you can fill it up with these types of stories. A book like this could be a huge hit, get this issue even more spotlight and maybe some fixes.
You want to try to change things? Great. So write the book!
In the early 2000s I got a job right out of highschool working at a Blue Cross Blue Shields call center. I thought it was going to be customer service but it was insurance claims. Training was supposed to be 6 weeks but they pushed me live after just 2. I had no idea what I was doing. After floundering for a couple weeks trying to learn to basically be a fuckin doctor, I just started approving everything. "Patient needs emergency surgery for X" "Approved". The whole experience was completely insane.
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I am a member of a community that had an extremely high rate of HIV infection, and watched dozens of people die, in the 1990s. It was pretty awful.<p>I found out that many insurance companies deliberately delayed approving procedures, in the hope that it would kill the patient.<p>back then, there was no AI. The decisions were made by humans.<p>Sometimes, people suck.
Medicare has a similar issue. When you sign up at 65, you have to make a first big decision, Traditional Medicare (yay!) or private Medicare Advantage (boo!).<p>Traditional Medicare consists of Part A (hospitals), Part B (doctors) and Part D (drugs). Part A+B don't cover everything so you have a Medigap plan. I have Plan G which has very little paperwork. All up, I spend about $400/mo and I'm very happy with A+B+G+D.<p>With Medicare Advantage you sign over your Medicare rights+benefits to a private insurer. This may save you some money, especially early on. In fairness, not really a lot and the $0/mo plans are a scam. With Medicare Advantage, you will then have to argue with an insurance company for the rest of your life. You'll have to deal with preauthorizations and a restricted network.<p>With Traditional Medicare, what's covered is spelled out pretty clearly ahead of time. Docs know it. You know it. There's literally an app for that. With Medicare Advantage, medically necessary is at the discretion of the private insurance company.<p>Here is the scenario from a relative: he had a heart event which ended up needing a stent. He had to argue with Kaiser while this was going on. Kaiser is 240,000 people. He is one.<p>Medicare Advantage is very profitable.<p>It is possible to switch back from MA to TM which really revolves around your Medigap plan. You are guaranteed issue for Medigap plans for about 3 months before/after you turn 65. After that, you will have to undergo medical underwriting.
Yes.<p>"Medicare Advantage" = HMO. All the usual HMO problems.<p>The best Medigap plan is Plan F, which is no longer available to new subscribers.
"Discontinuation of Medicare Plan F was a strategic decision aimed at promoting responsible healthcare spending and ensuring the financial sustainability of the Medicare program." It covers just about everything Medicare doesn't pay, including the various deductibles Medicare has. If Medicare covered Medicare's part, the Plan F provider has to pay their part. They don't get to question it. I don't even see hospital bills, just statements that it's been paid for.<p>Plan G is one step down from that.
The theory behind Medicare Advantage is that it would cost the government less than traditional Medicare because the private insurer would be more efficient. Guess what happened.
If you look at any health insurers profit split right now they are making all of their gains on medicare advantage.
> In 2022, Carelon settled a lawsuit for $13 million that alleged the company, then called AIM, had used a variety of techniques to avoid approving coverage requests. Among them: The company set its fax machines to receive only 5 to 10 pages.<p>Who are the people who sleep at night after designing these policies?
The worst part, simultaneously soul crushing and apocalyptic rage inducing is that we get these outcomes <i>after</i> spending more per capita on healthcare than pretty much any country on the planet.
Worse, we spend more <i>in tax dollars</i> on it than any other country <i>total</i>, and then add on the <i>private</i> spending on top. We do the worst of both worlds.<p><a href="https://commons.wikimedia.org/wiki/File:OECD_health_expenditure_per_capita_by_country.svg" rel="nofollow">https://commons.wikimedia.org/wiki/File:OECD_health_expendit...</a><p>(And we’re middling in outcomes!)
... and that money isn't going to insurers.
Evilcore is a fitting name.<p>> Connecticut’s Insurance Department recently reviewed EviCore and Carelon. It found no problems with Carelon. EviCore was fined $16,000 this year for more than 77 violations found in a review of 196 files.<p>$16k is such a low fine that it’d be funny if it wasn’t so sad. fines should be increased to actually represent a threat to the company - maybe as a % of yearly profit?<p>our system is so fucked dude
Medically speak, I'm sure we can all find several businesses that arn't necessary.
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yes... sarcasm...<p>Totally unrelated. In traditional stories, as anyone ever been upset when the knight slays the dragon at the end because the dragon was hoarding all the gold and killing the townspeople? I was never upset when the dragon got slayed.<p>EDIT: Yeesh. I guess people here really like it when the dragon wins. Oh well. I guess people have to die so the dragon can hoard the wealth.
have they managed to wrangle a jury yet?
Not even. Just look at it by the numbers. If one in every 10k, 20k, IDK but surely you don't even need 1:1k, life alteringly aggrieved people threw what was left of their lives away getting even instead of just taking it the sheer economics would make most of the bad stuff stop.<p>And make no mistake, this applies to just about everything, not just medical.<p>The suffering in society always reaches equilibrium with the pushback and modern people are very, very, very docile so we're made to suffer a lot.
<i>Geiz-ist-geil</i>-healthcare is, according to many election results anyway, what most US citizens want; everything else is communism/socialism/woke/leftist/[...].
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I think the vast majority of people agree on the generalities and care enough about solving the issue to be able to come to an agreement on the particulars. The problem is that the people who get rich off the current system won't agree to any solution that reduces their profits, and have thus far managed to fillibuster attempts at such a solution through a combination of buying politicians and propagandizing certain segments of the population into rejecting solutions that would benefit them.
Healthcare is ~17% GDP<p>Slavery was estimated at ~12% and "hey, you need to lose a few % of your margin and actually pay those people" started a war.<p>Now, there's an argument to be made about ideology, concentration of industry, etc. But the fact remains that you cannot make a large fraction of the country take a haircut without causing strife.<p>The only way to fix this "nicely" at this point is to boil the frog over decades.
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> It's not a money probelm, it's a resources problem.<p>Most people would consider money a resource, and quite a few rural hospitals are closing because of a lack of that specific resource.<p>> you'll discover how you really DONT want the government to tell you which patients to serve<p>Yeah, wait until you hear about private for-profit insurers doing that instead.
As an adult, i deal with private for-profit insurers all the time. If you're under 26, you've probably never paid a medical bill.<p>It's a money problem because the medicare doesn't pay enough to hosptals, and boomers are all on medicare.<p>So your government run healthcare is destorying rural hospitals.
Honestly, after stories like these, I don't want a corporation telling me which patients to serve even more. At least government is theoretically accountable for their decisions.
As long as you accept the outcome of “drop dead” when something happens to you.<p>Problem is you’ll go right to the emergency room when you have a heart attack.
What's a libertarians take on how health care should work? Completely privatized, completely socialized, somewhere in between?
The fact that the hospital doesn't know what a procedure costs (they make it up based on deals with medicare, medicaid, and individual insurance companies) should give you a hint.<p>Yes, the patient needs skin in the game. People need to take care of their own health. Most procedures are given to grossly unhealthy people.<p>Yes, completely privatize it. Make people pay for their care so their daily decisions are weighed against what affect it will have on their overall health.
“I’ll put out this fire for you if you pay me $5000”
"I don't want to be forced to pay for insurance, but will move to a state with subsidized insurance the second I need it."